St Thomas' Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

There was a positive safety culture where incidents were investigated, and learning was embedded to promote good practice. Staff were open and honest when things went wrong. Staff provided safe care and treatment. Most staff had the required levels of training to safeguard people at risk and knew what actions to take to keep people safe from avoidable harm and abuse. The environment was safe and met people’s needs. Leaders monitored staffing levels to keep the service and people safe. Staff were trained and competent and had the right skills to meet people's needs. They had opportunities for learning and personal development. Staff used systems and processes to safely prescribe, administer, record, and store medicines according to national evidence-based practice.

At our last inspection we rated this key question good. At this assessment, the rating has remained good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed a good standard. The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The trust had a clear process for reporting and learning from incidents. Staff reported incidents on the trust electronic system. Staff we spoke to knew how to report an incident. They confirmed they discussed learning from incidents during staff meetings and at handovers.

The service regularly reviewed patient safety incidents and analysed key themes. We reviewed the urgent and emergency care (UEC) patient safety incident data summary (February 2025 to February 2026). The summary identified key themes around the incidents. Key themes included patient aggression (28.6%), patient self-endangerment (20%), medication (10%), slips, trips and falls (7%), restraint and rapid tranquilisation (6.5%) among others. Most incidents reported (99%) resulted in either no harm or low harm. We saw evidence learnings were discussed from the notes of mortality and morbidity meetings, clinical governance and staff meetings. There were posters around clinical areas highlighting learnings from incidents and national audits. The service also shared learnings from complaints with staff and used feedback to improve the service. For example, the service improved the provision of refreshments following patient feedback about access to food and drinks in the ED.

Staff understood their responsibilities relating to the duty of candour and when this should be applied. The service followed the duty of candour policy by disclosing incidents to patients and providing feedback on investigation outcomes when necessary. We saw examples of this in letters written to patients and their families.

The evidence showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service had effective systems and clear pathways to ensure people received safe care and treatment in a timely manner. Data received from the trust showed that between February 2025 and January 2026, the service met the national performance standard to admit, transfer or discharge 78% of patients within 4 hours of their arrival in the ED. There was a television screen in all areas of the ED which kept people updated on current wait times. We observed this was updated regularly during the assessment.

On arrival, patients were seen by a streaming nurse who reviewed patients and directed them to the most appropriate care pathway. Patients were streamed to various areas including the GP centre, urgent care centre (UCC), same day emergency care (SDEC), and multidisciplinary assessment unit (MSAU). We observed that ED patients screened to the MSAU had been seen by the ED team, had care plans.

Patients could be streamed directly to the GP centre which saw patients with primary care needs. Staff informed us around 17% to19% of patients attending the ED were streamed to the GP centre. The service had a clear criteria for patients streamed to the GP centre, this included low acuity patients that do not require blood tests, imaging or other investigations.

Patients were seen by a triage nurse who completed a brief assessment including observations of vital signs and prioritisation of urgent cases. Our observation of triage and care pathways showed staff assessed people quickly and transferred them promptly when more specialist care was required. Between March 2025 and February 2026, the mean time to triage was 13 minutes for the adult ED and 18 minutes for the paediatric ED. The median time to triage was 3 minutes for the adult ED and 13 minutes for the paediatric ED.

The urgent care centre saw patients presenting with minor injury or illnesses. Patients with higher acuity were streamed to the majors area. This included the ambulatory majors area (referred to as majors C) where patients were likely to require diagnostic imaging, blood tests or other investigations. Patients requiring a cubicle, intravenous (IV) antibiotics and other interventions were streamed to the main majors area (majors AB) while the highest acuity patients were streamed to the resuscitation area.

There was an allocated doctor for rapid assessment and treatment (RAT) with the aim to quickly evaluate patients on arrival, initiate treatments or investigations and initiate early direct referrals. The service had a standard operating procedure (SOP) for patient referrals and transfers to other services. This included pathways for specialities like haematology, oncology, urology, neurosurgery and stroke among others.

We observed a seamless handover process between ambulance and ED staff with relevant information obtained about patient’s presenting symptoms, medications, and allergies. Data from the trust showed that between February 2025 and January 2026, the average ambulance handover time was 16 minutes. The quickest average handover time was 14 minutes in June 2025 and the longest was 18 minutes in January 2026.

The service had a Standard Operating Procedure (SOP) to escalate delays in triage or ambulance handovers. The SOP identified trigger points for ED triage escalation and for immediate ambulance handovers. For example, trigger points for the triage waiting area include more than 45 minutes wait for a trolley or more than 3 patients waiting for a trolley. Triage point for ambulance handover occur when there is less than 50% capacity to offload arriving ambulances. This prompted senior staff to review patients awaiting transfer and identify patients who could be rapidly moved to speciality teams.

The service had clear pathways for people presenting with various ailments including trauma, stroke, chest pains and sickle cell among others. The service had a standard operating procedure (SOP) for admitting sickle cell patients to the Multi-Specialty Assessment Unit (MSAU). The purpose of the SOP was to improve the care of patients with sickle cell disease who attended the ED at St Thomas’ Hospital. The SOP identified clear pathways for sickle cell patients based on their level of acuity. For example, acutely unwell sickle cell patients were admitted directly to the intensive care unit. Patients who did not require haematology input were admitted to the MSAU under care of the ED. Patients who required haematology input were admitted to the MSAU under the care of haematology or to a sister location.

The provider had clear pathways for patients attending the ED with mental health needs. The service had an enhanced care team which provided therapeutic interventions to support mental health and recovery. Staff could request the assistance of the enhanced care team to deliver 1-to-1 support for patients with acute mental health needs, drug/alcohol intoxication, likely to wander or abscond, experiencing psychological distress and deemed at risk of harm to themselves or others. The provider worked in partnership with a local mental health trust to care for patients with mental health needs. ED staff reported easy access to the psychiatric liaison team who operated 24 hours a day and had a member of staff available on site.

The provider also had a clear pathway for children or young people presenting to the paediatric ED with mental health needs. This involved referral to the Child and Adolescent Mental Health Services (CAMHS), safeguarding referral, completing the environment checklist to ensure the mental health room was ligature free, enhanced observations (were indicated) and liaison with speciality teams.

We observed long stays for some patients with mental health needs. This was typically due to long waits for transfer to specialist mental health services. The leadership were working proactively with the mental health trust to address this. All patients were seen by relevant speciality teams and had accessed timely treatment. The service established a crisis assessment unit (CAU) predominantly staffed by the local mental health trust. The CAU was used to accommodate patients waiting for mental health beds in a calm therapeutic area with motion sensor lights.

Staff working in the enhanced care team and the psychiatric liaison team had access to London wide records which included the individuals records from the mental health trust.

The service liaised effectively internally with speciality teams and externally with other health care providers to ensure there was always continuity of care when people moved between different services.

The evidence showed good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff we spoke with knew how to identify people at risk of, or suffering, significant harm or abuse and the service worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff received training specific for their role on how to recognise and report abuse. Most staff had completed the right level of safeguarding training for both children and adults in line with the trust target (90%). However, medical staff had lower compliance rate for child protection level 3 training (70%) and safeguarding adults training (81%). The trust stated staff were booked to complete any outstanding training. Following our assessment the trust provided updated training figures for child protection which now exceeded the trust target of 90%.

During our inspection, we reviewed notes of children in the paediatric ED and confirmed that staff completed safeguarding checklists and escalated concerns when necessary. Staff escalated concerns when children attended the service and left without being seen.

Staff had received training on using the Mental Health Act and Mental Capacity Act. We observed staff requesting MHA assessments where needed for a person to receive treatment at a mental health inpatient service and an informal agreement was not possible.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service had a safeguarding lead and staff found them approachable and supportive.

The trust had a safeguarding policy for adults and a separate policy for children which were up to date and available on the intranet. The safeguarding polices were comprehensive and reflected national guidance. The policies identified various forms of abuse including child sexual exploitation and female genital mutilation. The policies outlined actions staff should take when they identified a safeguarding concern. Staff we spoke to were aware of the policy and how to access it.

The service posted information signposting people for drug problems, drinking helpline, crystal meth and domestic violence support in toilets.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service had arrangements to support people to identify and mitigate individual risks. Staff completed risk assessments for each patient using a recognised tool. This included identifying potential risks such as allergies and assessing patients’ suitability for treatment. There were flags on the electronic system to identify vulnerable patients. This included patients who had communication needs, patients at risk of falls, infectious patients or patients who required additional support. We reviewed electronic notes of children and young people which highlighted flags for children in need, children with a child protection plan and any other safeguarding concern.

Staff used the National Early Warning Score (NEWS) and Paediatric Early Warning Score (PEWS) to identify adults and children at risk of deterioration. Observations were recorded in 32 patients’ records we reviewed, and we saw information which confirmed monitoring of staff’s completion of these assessments was carried out regularly. Staff were able to describe the process of managing deteriorating patients. During our inspection, we observed staff monitoring NEWS scores and identifying patients at risk of deterioration and escalating treatment in line with national guidance.

We observed majority of patients had appropriate frequency of observations and we saw good evidence of nursing documentation for waterlow scores, falls risk, frailty score and pain score.

Most staff had completed resuscitation training including advance life support training and advance paediatric life support training to manage life threatening emergencies. Where new staff had joined the department they were booked on the next available training dates in June and September.

During our inspection, the main adult ED was piloting the use of the national acuity tool to triage patients. This had a 2 stage model which involved a primary assessment and a secondary assessment. The primary assessment rapidly identified immediate (acuity 1) and imminent (acuity 2) threatening illness or injury. It also identified less urgent cases (acuity 5) which may best be met by a primary care or other provider. The secondary assessment used additional clinical information, NEWS and mental health assessment to allocate patients’ acuity to a score of 3 or 4.

There were several prompts on the electronic system for staff to complete during triage. This included a prompt to complete a sepsis screen when NEWS is 5 and above. There were also prompts to complete a frailty score for people aged 65 and above. Triage staff recorded pain scores on a scale of 1 to 3 and used age appropriate pain assessment tools for children and young people. The system also had prompts to escalate patients for senior review when necessary, for example, patients experiencing chest pain or abdominal pain.

We observed the triage process in the paediatric ED and saw staff used the Manchester triage tool to quickly assess urgency and prioritise patients. Staff completed PEWS scores and safeguarding checklists. Paediatrics had a frequent attenders review process called Needs Exploration and Support Team for Emergency Department attenders (NESTED). This was a structured weekly meeting with north Lambeth paediatricians, north Lambeth GP’s and a paediatric emergency medicine consultant from the Evelina London team. They discussed patients who attended at least 5 times in a year and management plans.

Triage staff completed an initial mental health assessment for patients attending the ED.

The initial mental health assessment identified a potential level of risk of self-harm. For those with a medium or high risk the general nursing staff were prompted to take several actions to meet the persons immediate mental health needs. This included seeking additional support, considering moving the person to a safer environment and offering to carry out a search. Staff working in the ED considered if adults with mental health needs should be encouraged to let nursing staff carry out a search of their personal possessions to remove anything which they might use to harm themselves including medication or sharp objects. Nursing staff we spoke with said they found the assessment process user friendly and found the prompts helpful in planning the next steps.

Staff working in the ED were prompted to consider if adults and young people with mental health needs should be supported by the enhanced care team who could offer 1 to 1 observation. This enhanced care was mostly delivered by band 3 staff and they were supervised by a band 6 mental health nurse. Most staff had completed training on therapeutic engagement including how to carry out enhanced observations and further training for more recently employed staff was scheduled for April 2026. Staff from the enhanced care team were able to explain how they carried out the observations, and we saw staff undertaking this role in a considerate and respectful manner.

The enhanced care team carried out in-depth mental health assessments and developed a risk assessment with a management plan. Where possible these were discussed and agreed with the individual. The most recent audit of the Royal College of Emergency Medicine Mental Health (Self-harm) standards of care showed the trust was below average for the documented mental health triage taking place within 15 minutes. This was an area where the trust was working to make improvements.

ED nurses also referred patients to the psychiatric liaison team, who carried out a detailed psycho-social assessment as needed. The most recent audit of the Royal College of Emergency Medicine (RCEM) Mental Health (Self-harm) standards of care showed the trust was above average for parallel assessments taking place but needed to improve the time taken for the initial assessment by the psychiatric liaison nurse.

The trust had up to date guidance for staff caring for people at risk of suicide. It included a flow chart for staff in the ED to follow. This included guidance for staff on how to develop a collaborative suicide safety plan with patients and carers to help mitigate the risk of self-harm.

The service maintained a database demonstrating staff had completed competencies on patient triage and assessment. The service allocated adequate staff to manage triage. This included 5 registered nurses (including a senior staff nurse) and a Senior Nursing Assistant (SNA). Triage staff had good knowledge of mental health assessments, special requirements for learning disabilities and how to raise safeguarding concerns.

The ED had created a sheltered area outside the department for walk-in patients to queue (during high activity periods). The service had an escalation plan which allocated an additional streaming nurse once there were up to 6 people on the queue. The streaming nurse observed patients on the queue to identify sick/acutely unwell patients for immediate prioritisation. The service completed monthly audits to determine the length of time patients spend on the queue. We reviewed 7 audits carried out between March 2025 and February 2026 which showed most patients spent less than 4 minutes in the queue before their interaction with the streamer. In addition, the service had implemented plans to launch a welcome kiosk in April 2026 enabling patient self-registration via iPads.

Staff working in the ED were trained about how to call for support in the event of a patient harming themselves or others. Nursing staff had access to mobile alarms which could be activated. There were also wall alarms. Staff could call a number to summon assistance from other nominated care professionals and security staff if needed. Regular drills were held to ensure staff knew how to call for assistance. Posters displayed told staff how to call for help. Security staff were available to support the patients and staff as needed.

Leaders understood the need to improve sepsis screening, and this was an ongoing area of focus for the service. However, we identified a case where a patient (who had been on chemotherapy) was not screened on arrival contrary to the trust sepsis policy. We noted that the patient was promptly escalated for medical care and treatment upon deterioration. We raised this case with the trust for response. The trust highlighted several quality improvement projects (QIP) aimed at reviewing or improving the sepsis pathway. This included a review of incidents covering the period between March 2025 and March 2026. Results showed there had been no incident identified as causing moderate or serious harm where staff failed to identify sepsis or act on an acutely deteriorating patient.

The trust informed us they would embark on the next phase of work to encompass the variety of triggers for sepsis screening such as recent chemotherapy or immunosuppression using flagging systems on the electronic patient records.

The evidence showed a good standard. The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises and facilities supported the delivery of safe care. Patients were allocated to different areas of care depending on the severity of their condition: resuscitation unit, majors, ambulatory majors, UTC and the GP centre. Areas were well maintained and monitored to deliver safe care. Patients were not cared for in non-designated areas, such as corridors throughout the period of our inspection. There was limited access to certain areas of the ED with access only gained by swipe card or intercom which created a secure environment.

Self-presenting patients entered the ED through a dedicated entrance. There was a waiting room in front of the triage cubicles. The layout of the main waiting area meant staff had sight of patients in this area. However, we were informed that patients often queued in a sheltered area outside the ED during high activity periods. The service had an escalation plan which allocated a streaming nurse to the queue once there are up to 6 people queuing.

Diagnostic imaging facilities were co-located in the department which allowed for diagnostic procedures to be completed quickly if patients were waiting for a specialist review.

The paediatric emergency department was co-located but physically separate from the main ED. It could be accessed by authorised persons via a swipe card or the intercom. There was a separate paediatric waiting area inside the department. Staff in the paediatric department could see into the waiting room and identify a deteriorating patient.

The service had facilities for people with mental health needs. The trust had carried out ligature risk assessments and there were plans being implemented to carry out further ligature reduction work. There were 2 mental health rooms in the majors area. One was a high-risk mental health assessment room and the other could be upgraded to a high-risk room if required. Both rooms were ligature free. They both had 2 doors which were anti-barricade and had an alarm. There was appropriate furniture in the first room. In the second room there was a hospital bed which could be removed if needed.

The trust had started the process of gaining accreditation to confirm they had met the Psychiatric Liaison Accreditation Network (PLAN) standards. A self-assessment was in the process of being completed as part of the accreditation process.

There were 4 rooms designed for people with mental health needs in the crisis assessment unit. Two were ligature free including the ensuite bathrooms. The other 2 were mostly ligature free but were waiting for anti-ligature bathroom doors and appropriate beds. These had been ordered at the time of our inspection.

The paediatric ED had 1 room for children and young people with mental health needs. The service had carried out ligature reduction work in the room; however, it was not completely ligature free. There were no plans to develop a fully ligature free room as the limited availability of cubicles meant that each area needed to be used for babies and young people with physical and mental health needs. This was mitigated by an early risk assessment, and where needed, input from the enhanced care team.

The trust had acquired 4 safety pods, which were large bean bags. These pods were used for patients who wanted to relax but could also be used when restraining people as an alternative to them going on the floor. The accredited restraint trainer had trained the security staff to use the pods.

Ligature cutters were available in the top drawers of the crash trolleys across the ED. Staff had received online training on how to use ligature cutters. The department lead nurse had just bought new and improved ligature cutters. However, when asked staff were unclear on the location of the ligature cutters. Immediately after the inspection staff were reminded of where to find them.

We found scissors kept in the cupboards in the majors’ cubicles; this included a cubicle were a patient at potential of self-harm was accommodated. We escalated this issue to senior staff. The trust informed us all cubicles had the ‘tough cut scissors’ as part of majors cubicle kit for use of clothes removal. The department had reviewed and removed these ‘tough cut scissors’ because on balance the need for the scissors in each cubicle is a lower risk because staff could obtain them from the Omnicell and in an emergency from the crash trolley. The trust informed us that the majors checklist had been amended to reflect the change and this was communicated to staff.

We checked equipment for PAT testing in ED areas visited and found that most equipment was tested yearly. However, we found 2 pieces of equipment in the paediatric ED that were out of date for testing. This was escalated to the trust and the trust took prompt action to address this.

Staff carried out daily safety checks of specialist equipment. We reviewed random supplies in trolleys in ED areas and found most in date. However, we found some out of date supplies in tracheostomy emergency trolley by the paediatric resuscitation bed area. This was escalated to senior staff and immediately removed, disposed and restocked. We also found out-of-date supplies in an adult emergency box kept on top of the tracheostomy trolley. This was also disposed of and restocked.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service planned and regularly reviewed staffing levels and skill mix to ensure people received safe care and treatment.

Staffing levels were in line with the national guidance of 1 nurse to 4 patients. ED nurse staffing consisted of 25 registered nurses and 7 SNAs during the day and 24 nurses and 6 SNAs at night.

Staffing during our inspection was safe and met the demand on the ED. The service adhered to minimum staffing levels daily for both medical and nursing staff. Nursing rotas were prepared 6 weeks in advance and any shortfall was filled with bank staff. Senior staff also stepped in to support staff were necessary.

The GP centre was staffed by 4 GPs and 1 SNA while the UCC was staffed by 4 emergency nurse practitioners (ENPs) during the day and 2 at night.

There was consultant presence in the adult ED between 8am and 12am, Monday to Friday 7 days a week in line with the Royal College of Emergency Medicine (RCEM) recommendations of 16 hours per day. On call cover was provided out of hours. A team of specialty registrars and other resident doctors were rostered to provide cover for 24 hours a day, 7 days a week.

Paediatric nurse staffing in the paediatric ED and the 6 bedded Children's Short Stay Unit (CSSU) consisted of 1 band 8a matron, 8.86 full time equivalent (FTE) band 7 nurses (which included 1 practice development nurse and a trainee advance clinical practitioner), 10 band 6 nurses and 9 band 5 nurses which included rotational nurses. There were 4 SNAs and 1 play specialist. During our inspection the paediatric ED was staffed by 7 nurses, 1 student nurse, 1 SNA and 1 play specialist.

Medical staffing in the paediatric ED and the CSSU consisted of 16 (8.2 FTE) consultants, 6 specialty registrars and 12 senior house officers (SHOs). Paediatric ED consultant cover was from 08:00 – 22:00, 7 days a week. On call cover was provided out of hours. Other medical staff were rostered to provide cover for 24 hours a day, 7 days a week. Staffing data for the trust showed 88% fill rate for resident doctors in the paediatric ED.

The ED had access to an enhanced care team available to therapeutically support adults and young people with mental health needs. The team was managed by the departmental head of nursing for mental health and supported the other professionals in the ED to deliver safe and effective care. At the time of the inspection the enhanced care team consisted of a mental health matron, 2 band 7 team managers, 10 band 6 registered mental health nurse shift leaders, and 52 band 3 staff. The team worked 24 hours a day with 1 to 2 shift leaders and 10 band 3 staff available. The team supported people with other needs such as patients with dementia.

The service had practice development nurses who have developed a robust induction and training program for nursing and support staff. This included mandatory training, band development training, Royal College of Nursing competencies, and capital nurse ED qualifications. Medical staff had dedicated and protected time for training. Staff spoke well about the opportunities for training and personal development.

Staffing data provided by the trust showed that by January 2026, the vacancy rate was 9.2% in line with the trust target of less than 10%. The ED was also in line with the trust target for its agency staff spend (2.2%), sickness absence rate (3.9%), and annual turnover 9.3%.

Senior staff informed us they had good retention rates and staff we spoke to confirmed that they enjoyed working in the department. The ED covered vacancy rates with the use of bank staff as the unit rarely used agency staff.

The enhanced care team undertook a mental health skills training day. This included sessions on therapeutic engagement which included training on enhanced observations and de-escalation. At the time of the inspection 86% of the nursing assistants had completed the training and some recently recruited staff were booked to receive this training in April 2026.

The main ED overall compliance with mandatory training was 90.6% against the trust target of 90%. Overall compliance rates for nursing (92.7%), allied health professional (100%) were above the trust target while the overall compliance rate for medical staff (82.6%) was below the trust target.

The overall compliance with mandatory training in the paediatric ED (87.3%) was slightly below the trust target. Compliance rate for nursing staff was 91.3% while compliance rate for medical staff (79.4%) was below the trust target.

At the time of the inspection, staff were booked to complete outstanding mandatory training modules across ED services.

Staff had completed an induction and competencies to carry out their role. The appraisal rate for ED was 92%. This was above the trust target of 90%. As of December 2025, the appraisal rate for staff in the paediatric ED was slightly below the trust target for nursing (87.5%) and medical (89.5%) staff.

The revalidation rate for nursing and medical staff in the paediatric ED was 100%.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed that all areas of the service were visibly clean. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly.

Staff were ‘bare below the elbow’ and adhered to infection control precautions throughout our inspection, such as hand washing and using hand sanitisers when entering and exiting the unit and wearing personal protective equipment when caring for patients.

There were handwashing sinks available. Soap and disposable hand towels were available next to sinks and instructions on how to effectively decontaminate hands were displayed above the sinks. We observed staff wash their hands in-between patient contact.

We observed equipment was visibly clean during our inspection. We observed staff clean equipment used for patients. The service used “I am clean stickers” to identify pieces of equipment that had been cleaned and ready for use. Disposable curtains were labelled with the date they were last cleaned. This was within a week of our inspection.

Domestic staff we spoke with confirmed they had received training to work in their role. They explained that there were dedicated waste disposal areas for different types of wastes including infectious waste. There were adequate arrangements for handling, storage and disposal of clinical waste, including sharp instruments. During our inspection we observed sharps bins were correctly assembled and labelled in line with national guidelines.

The service carried out monthly cleaning audits covering all areas of the ED. The latest result provided for the paediatric ED showed the service achieved 97.3% compliance in January 2026. The latest audit result provided for the main ED showed that the service achieved 98.8% compliance in February 2026. Areas of non-compliance were communicated to staff to facilitate improvement.

The service carried out monthly hand hygiene audits. Results from the audit showed that the main ED achieved a low average compliance score of 74% between September 2025 and January 2026. The audit identified areas of compliance for improvement. By February 2026 the compliance score had improved to 90.9% and the service was rated green.

Results of the hand hygiene audits for the paediatric ED showed that the service achieved a compliance score of 90.6% between November 2025 and January 2026 and was rated green.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely. The service had a medicines management policy, which described the handling, storage, prescribing, recording, safe administration, and disposal of medicines.

Staff completed medicines records and kept them up to date. We reviewed patient records which showed prescription charts were completed, signed, and dated. Staff recorded information about patient allergies.

We found medicines were stored securely and appropriately. We reviewed the controlled drugs register which was correctly completed and noted the entries had been signed by designated members of staff as required. Medicines we checked were in date and reconciled with the records.

Medicines requiring cold storage were stored in locked fridges and the temperature was monitored daily.

The trust ensured that where patients needed intra-muscular rapid tranquilisation medication that arrangements were made for this to be administered safely and only when other options had been tried.

The trust had carried out an audit into the use of rapid tranquilisation for 46 patients in August and September 2025. This identified the need for improved recording and more explicit post rapid tranquilisation review plans. Following the audit, the trust finalised a new version of the protocol for managing acutely agitated patients which included when it was appropriate to use rapid tranquilisation, and are auditing the impact of this. It identified decision makers that can apply the protocol and included the need for 15-minute physical health monitoring over a 2 hour period following the administration of rapid tranquilisation. Staff told us that rapid tranquilisation was administered in the resuscitation area of ED so the appropriate monitoring could take place.

Most staff across ED services were up to date with medicines management training.

The service had a medication safety working group which reviewed medication safety in the ED, ensured safety issues were highlighted and disseminated to staff and guidance was updated.